HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOARD O '�, � '_ �
� � APPLICATION FOR LICENSE/PE {X �-� r lF�. � �' '� � �, ' �,�R`� (� q zO1�
O�n.O.. �.i.�t .;. ..�.. �� '�'
* Please complete form and attach all necessary do`" en s by Decem r 1 DEPT.
Failure to do so will result in the return of your application pac
ESTABLISHMENT NAME: `�` �- AX •
LOCATION ADDRESS: �`3-��-S�-v1� ��'C' TY uE� TEL.#: �3�!c� (o ('"vJ
MAILING ADDRESS: ��r-na �
OWNER NAME: �� f�G9�`��r�' '" �
CORPORATION NAME(IF APPLICABLE):
1VIANAGER'S NAME: .i�S V!"�j/ ` GYt�/ TEL.#: �'�'�/G� v
MAII,ING ADDRESS: .�"�y��
POOL CERTIFICATIONS: �
The pool supervisor tnust be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certif'ication to this form. �
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1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: i
All food service establishments are required to have at least one full-time employee who is certified as a Food i
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ,
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment. �
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1. 2. !
PERSON IN CHARGE: _-- __--- - - — --- __---___-_ -- -- -- _ __
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Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. !
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich `
Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and ;
attach copies of employee certifications to this form. The Health Department will not use past years'records. i
You must provide new copies and maintain a�le at your place of business. f
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1. 2. ,
3. 4,
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY '
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
_B&B $55 _CABIN $55 �MOTEL $55 �"/�–�QS !
_iNN $55 _(,AMP $55 _SWIMMING POOL $80ea. .�
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. i
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100SEATS $85 �CONTINENTAL $35 lo�"�� _NON-PROFIT $30
_>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80
RETAII.SERVICE: —RESID.KTI'CHEN $80 i
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 �
_Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO , $95
NAME CHANGE: $is AMOUNT DUE _ $ 9D• O�
�****PLEASE TURN OVER AN�COMPLETE OTHER SIDE OF FORM*****
5 7
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OIZ
CERT. OF INSURANCE ATTACHED
. OR ,
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED k
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Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOT�L�A�+TI3��r�lt g.�3i3��i�iG�STAiB$�.IS��TT'�u. _ _ ._
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected �
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days i
prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count �
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly ;
thereafter.
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POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of I
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPEI�TING: '
All food service establishments must be inspected by the Health Department prior to opening. Please contact the '
Health Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
- ��' �'. .,-�t�r��..-����:�Ki���:��s:��se��;ee3,�;t k�a�e�*�rrroy�l fr��.���]c�f He�lt�= -
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 1S, 2011.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENC NT. RENOVATIONS MAY RE U A ITE PLAN.
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DATE: � � SIGNATURE. l'
PRINT NAME&TITLE: ��-cl�,�'�`'�'1 �`l���� � �1���I.fG�
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� Rev.10/25/ll
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`�"� The Commonwealth of Massachusetts
Deparhnent of Indastrial AcciJents
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. 600 Washingtnn Street, �"'Floor .
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. , Boston,Mas�,02111 _ _ , :
�orl�ers'Compensatioe Iasorance A,�fi�vit- . : . _ , - ,`
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i C�' l.C�i� tate: zi ��� - l� ��L ' � 6/
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work site lceation(full addressl:
❑ I am a homeowner perfomning all work myseif.
❑ I am a sole proprietor and t�ave no one working in any capacity.
� I am an employer providing workers'compensation For my employees wodcing on this job. '
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. ❑ I am.a sole proprietor,ge�eral costnctor,or domeor►eer(circle one)and have hined the c�nhactas listed below who�have
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tl�e following wockers'compensation polices: , �. '
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eepy ot tii��faeeoe't mr 6e firwarded bs t!e Omee et l��s of the DIA tar avverase verMaUw
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ef5slai:e�e edy: 'dp net write'h this are=Ro be csa�pleted by city ar 6�wn o�1 ' : -
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� . WARK�RS CC711APEt�SAT90N A.NQ El4lPLOY�Ra' �.�A�I�.TY
lNSt�i�ANCE Q{?!�l�� ----1NIFQR�'dAT�C1N i�AG�
il�SliFtER: Pt3LiCY NO: GnTE�83�8 aA
Z1�RFOLK E& BEDHA:`.d �L7TUAL ��ItE ZNSURANCF GOMPANX ��oRBEMENT EFF a?I�-������
� 22� AI�t�S STREET � �
T3EDHAM, M�s C?2026 NCGR Com�:�ry ^�o: 2:.059
Acc�aunt No:
���rv:
I !i"�t�A �. N�►MEC� !PV atlR£D 1�►I'�D h1Ail.lNG A�DRESS� S�NSONA�aUNG��D�'4-�'WN� INa
SASS FtIVER FiECREATZC)N I3VC AGC�C
7 a ,9�T,7i'�i �HGR£ DRIVE: 5 b SA ROUTE 2�
����r2x �rAr�r��vTH t�A 0.,664 j��ortant po so� 158
PIEASE ATiACH TH1S HARSSAIII CH P OR'�"� MA O 2 6�5
ElVeQRSEM�NT
_ -- _ --- - TO Y�uR P�LIGY AGElVT NO.: 2{14 I 3
�.�G�L EN'�ITY: ^QRPCR�TIAN
s�'Th��R IiYi�RKP�+C�S �f�OT�Ht}WN ABQAI�: (See VI,'�:rkers C�mpenaat�c�R Giassificati�n Schedul��
��'�l�A 2. I'OLICY PEt�iQD: From: �70�.2,�2t�ls �'o: 07 f 1�./2�12
Effective 12:C'! A.M. Standar� Tin�e�tt the insur�d`s m���ing at�tireSSa
RT�Ni �, C�VERAGE.
A. '1t/�rkers�or�ipens�t�on Insura�ce: F'art t�ne r�f the�olicy app'sies to�he Vit�orkers Gc�t�pensa.ic�r�Law��tli�
S�ates NSt�d tt8re:
M�
�s. Ern�loyers' l.iab+lity Insuranc�: °art Two of the �a4icy appiie�ta work in each stat� Gstad in Piem 3.A.. 'i'f�e �i»-�dts
of l�at�ii{ty uri�ier Part Two ar�:
Bodily 4njury by r�,cci�ent: $ S A�,t?0:3 each accid�r�t
Bedi}y lnj�ry by E�issas�: $ 500, ��JO poi��y fir�roit
Bo�'sty inii�'ry by t3ise�: --_� �$ _5 0 0,.O O Q each er�p6oyee
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!: �therSta#e� Ir.surance: Part Ti�re�of the poliey applies te ih�stat�s, �f an�, !+�ted here: -
a�E ENDC RSEM��NT WC �'� 0� Q 6 A
�. Ttris�alicy u�c�udes thess Endorsemen4s and S�hedufes:
S�e Sc�e�ule of Fo�ms sr�d Endors�ements.
tTCh1 �. PR�MIUM: 'Th�premi��rn for th'ss Policy wit8 be d�termi�n�d by our Ma��uals�t Ru',es, Classificati�ns, R�tes an� '
Rating P"ar•.e�. �1► miormatian r��vi�ed t�r�the Wc�rlcera Gom�er�sat�on Glasssf�ca"ion �cheduie is s�,bjE��t t;�
veri�ic�t;vn ��nd cha;ige by audit. Tataf Estimated
231 Annuai Prern,ium: $ �., Q94
Uti^irt',um Pr8lr:lum: $ 42 AI�DITIC��T.AL
t�ud;t reri�C. AN�L1dA�.L Additic�nal!R�tum FrP.+'�ium: �
Com��ne�tu : CHAY�IIGE �AYRf3LL PER �.UD�T
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65sued At: `' .�
C�a!e: Ci E�/:�0,�2 L�'L 1 �o�nt�rsi�°�eci by '
�� �,����1 � Ga�y��ghk i387 N�Eiore!Counail an Compersatio�+Insurance
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